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A study to determine the type and frequency of interruptions sustained by postcardiotomy patients in… Nicholson, Billie Patricia 1974

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A STUDY TD DETERMINE THE TYPE AND FREQUENCY OF INTERRUPTIONS SUSTAINED BY POSTCARDIOTOMY PATIENTS IN AN INTENSIVE CARE UNIT by B I L L I E PATRICIA NICHOLSON B.N.-, MCGILL UNIVERSITY, 1965 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING In the S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e o u i r e d s t a n d a r d . THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1974 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f The U n i v e r s i t y o f B r i t i s h C o l u m b i a V a n c o u v e r 8 , C a n a d a ABSTRACT The environment of the intensive care unit is cited as one etiological factor of postoperative psychosis in patients follouing open-heart surgery. This descriptive study uas undertaken to document the type and frequency of interruptions sustained by post-cardiotomy patients in one intensive care unit. The study uas designed to ansuer three questions: 1. Hou frequent are the interruptions sustained by these patients? 2. Hou long are the blocks of uninterrupted time? 3. What are the types of interruptions? To collect the data a checklist of interrupting activities uas uti l i z e d . The sample included 108 hours of observation that covered the f i r s t f i f t y - s i x postoperative hours. These hours uere divided into early, mid, and late postoperative periods uith thirty-six hours of observation in each period. To f a c i l i t a t e continuous observation, the observation periods uere divided into four-hour blocks. A random sampling of the four-hour time blocks in each postoperative period over the days of the ueek uas carried out. A descriptive analysis of the data collected centered around the three questions. Also, t D f a c i l i t a t e analysis of data the types of interruptions uere organized into four main categories: (1) nursing activities, (2) patient initiated activities, (3) activities i i i i i • f cithers, and (k) environment. Basic to the d iscuss ion of the data uiere the fa l lowing f ind ings reported in the l i t e r a t u r e : (1) adults require e ighty -f i v e to ninety minutes to complete one sleep c y c l e , (2) there i s a close resemblance betueen the psychosis of s leep depr ivat ion and postcardiotomy psychos is , and (3) the environment of the pos tca rd -iotomy in tens ive care unit i s not conducive to g iv ing pat ients time for rest and s l e e p . U i th in the l i m i t s of the small sample s i z e the f ind ings of the study ind icated that pat ients uere f requent ly i n t e r r u p t e d . Second, the in ter rupted time blocks are not long enough for pat ients to obtain res t and s l e e p . F i n a l l y , nursing a c t i v i t i e s uere respons-i b l e for 50 percent of the i n t e r r u p t i o n s . These f ind ings supported the f ind ings of other s tud ies undertaken in the postcardiotomy intensive care u n i t . In a d d i t i o n , imp l i ca t ions and recommendations far nurses regarding management of these pat ients were d i s c u s s e d . F i n a l l y , recommendations for fur ther inves t iga t ion uere suggested. TABLE DF CONTENTS LIST OF TABLES 6 ACKNOWLEDGEMENTS B Chapter I . INTRODUCTION TO THE STUDY 1 Int r o d u c t i o n 1 Statement of the Problem 3 S i g n i f i c a n c e of the Problem 3 Assumptions of the Study k D e f i n i t i o n of Terms 5 L i m i t a t i o n s of the Study 5 I I . REVIEW OF THE LITERATURE 7 Int r o d u c t i o n 7 The 24-Hour Sleep Wakefulness Cycle 8 Stages and Patterns of Sleep..... 10 Sleep Dep r i v a t i o n Ik Postcardiotomy Psychosis 17 Environment of the Postcardiotomy Intensive Care Unit 18 E x i s t i n g Nursing Research 20 Summary 2D I I I . METHODOLOGY 22 Int r o d u c t i o n 22 Adaptation of the Tool 22 C h e c k l i s t of I n t e r r u p t i n g A c t i v i t i e s 22 The S e t t i n g 2k P a t i e n t Care A c t i v i t i e s 25 The P i l o t Study 26 The Sample • 27 C o l l e c t i o n of the Data 28 Summary 29 IV. ANALYSIS OF THE DATA 30 Pres e n t a t i o n of Findings 30 Frequency of I n t e r r u p t i o n s 30 Length of Uninterrupted Periods 31 Types of I n t e r r u p t i o n s 34 Discussion of Findings kO Summary k2 i v V Chapter V. SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING CARE, RECOMMENDATIONS FDR FURTHER INVESTIGATION 43 Summary.... 43 Implications and Recommendations for Nursing Care 45 Recommendations for Further Investigation 46 BIBLIOGRAPHY 47 APPENDIX A. Checklist of Interrupting Activities 52 B. Categories of Types of Activities 54 C. Random Sample of Time for Observation Periods... 56 D. Tables Related to Uninterrupted Time Blocks 58 E. Tables Related to the Types of Interruptions.... 62 F. Number of Patients Observed by Sex According to Type of Surgery 66 G. Tables Related to Interrupted and Uninterrupted Time 68 LIST OF TABLES 1. Average Time in Minutes Betueen Interruptions in the Four-Hour Time Blacks in Each Post-operative Period 31 2. Number and Duration of Uninterrupted Time Blacks in the Three Postoperative Periods 32 3. Average Number and Duration of the Uninterrupted Time Blocks in the Four-Hour Blacks in the Three Postoperative.. Periods 33 k. Number and Percentage of Interruptions in Each Category uithin the Three Postoperative Periods... 3k 5. Number of Interruptions in the Types of Activities in the Three Postoperative Periods 35 6. Percentage of Interruptions by Types of Nursing Activities in the Three Postoperative Periods 37 7. Percentage of Interruptions by Activities of Others in the Three Postoperative Periods 37 8. Percentage of Interruptions by Environmental Activities in the Three Postoperative Periods..... 38 9. Average Number of Interruptions in the Categories of Activities in the Faur-Hour Blacks in the Three Postoperative Periods 39 10. Number and Duration of Uninterrupted Time Blacks in Each Four-Hour Black in the Early Post-operative Period. ; 59 11. Number and Duration of Uninterrupted Time Blocks in Each Four-Hour Block in the Mid Postoperative Period 60 12. Number and Duration of Uninterrupted Time Blocks in Each Four-Hour Block in the Late Postoperative Period 61 vi u i i 13. Number of Interruptions in the Types of Activity Uithin the Four-Hour Time Blocks in the Early Postoperative Period .... 63 14. Number of Interruptions in the Types of Activity uithin the Four-Hour Time Blocks in the Mid Postoperative Period 64 15. Number of Interruptions in the Types of Activity uithin the Four-Hour Time Blacks in the Late Postoperative Period 65 16. Number of Male and Female Patients Observed According to Type of Surgery 67 17. Number of Minutes of Interrupted and Uninterrupted Time in Each Four-Hour Block in the Early Postoperative. Period 69 18. Number of Minutes of Interrupted and Uninterrupted Time in Each Four-Hour Block in the Mid Postoperative Period 70 19. Number of Minutes of Interrupted and Uninterrupted Time in Each Four-Hour Block in the Late Postoperative Period 71 i ACKNOWLEDGEMENTS I uish to express my appreciation to the many people uho made this study passible: to the nursing staff in the post-cardiotomy intensive care unit for their interest and cooperation; to Ms. Helen Elfert for her help uith the analysis of data; to the members of my committee, Ms. Mary Cruise and Ms. Sue Rothuell, my committee chairman, for their advice and guidance; and to my classmates for their interest and support throughout the progression of this study. v i i i CHAPTER I INTRODUCTION TO THE STUDY Introduction Along uith other advances made in medical science over the past twenty years great strides have been made in open-heart surgery. Although many patients have benefited from the different cardiotomy procedures one untouiard response, postoperative psychosis, has been noted in many of these patients during their stay in the intensive care unit. Postcardiotomy psychosis has been reported to appear in approximately 38 percent to 57 percent of adults uho have open-heart surgery. This syndrome is manifested after a three to five day lucid postoperative period and is characterized by: perceptual distortions, visual and auditory hallucinations, disorientation and paranoid ideation.^" A revieu of the research reveals l i t t l e agree-ment about the etiology of this postoperative reaction. Although many factors have been identified as the cause, i t appears to re-sult from an interaction among several factors, some physiological in origin and others related to psychological stress. "'"Donald S. Kornfeld, "Psychiatric Complications of Cardiac Surgery," International Psychiatric Clinics 4 (February 1967): 115. 2 Linda H. Aiken and Theodore F. Henrichs, "Systematic Relaxation As A Nursing Intervention Uith Open Heart Surgery Patients," Nursing Research 20 (May-June 1971): 213. 1 i Houever, one etiological factor that is of particular concern to nurses and one that is partially controllable, is the environment of the intensive care unit. Kornfeld's study paid particular attention to the environment of these areas to see i f i t uas a contributing factor in postoperative psychotic reactions. He concluded that: A major factor appeared to be the environment of the open-heart recovery room, uhere intensive nursing and medical care produced an atmosphere of sleep and sensory depriv-ation. ^  Lazarus also carried out studies on the environment of the postcardiotomy intensive care unit. He stated: Patients frequently complain of the frightening atmosphere, the lack of sleep, the feeling of being physically re-strained and the unusual and disturbing sounds to uhich they are exposed.^ These tuo studies recommended the modification of nursing procedures to allou for a maximum number of uninterrupted sleep periods. Also Kornfeld suggested that the usual day-auake, night-sleep cycle for each patient should be maintained uhenever possible. Cardiotomy patients and nurses uho uork in postcardiotomy intensive care units agree that interruptions to patients' sleep and rest are too frequent. In reviewing the literature there appears to be l i t t l e research that looked at kinds of interruptions sustained "^Donald S. Kornfeld, S. Zimberg, and J . R. Malm, "Psychi-atric Complications of Open-Heart Surgery," The Neu England Journal  of Medicine 273 (August 1965): 292. . H. R. Lazarus and J . H. Hagens, "Prevention of Psychosis Follouing Open-Heart Surgery," American Journal of Psychiatry 124 (March 1968): 1190. 5 Kornfeld, "Psychiatric Complications," p. 291. 3 by these p a t i e n t s . Nurses are res p o n s i b l e f o r the o r g a n i z a t i o n of nursing care. In order to modify the o r g a n i z a t i o n of nursing care, nurses must be auare of the type and frequency of i n t e r r u p t i o n s experienced by pa t i e n t s i n these areas. Statement pf the Problem The purpose of t h i s e x p l o r a t o r y study uas to document the type and frequency of i n t e r r u p t i o n s sustained by postcardiotomy / p a t i e n t s i n an i n t e n s i v e care u n i t . This study uas designed to ansuer the f o l l o u i n g questions: 1. Hou frequent are the i n t e r r u p t i o n s experienced by these p a t i e n t s ? 2. Hou long are the blacks of uninterrupted time? 3. What are the types of i n t e r r u p t i o n s ? S i g n i f i c a n c e of the Problem Sleep i s one of the f a s c i n a t i n g mysteries of l i f e . Everyone needs s l e e p . The f u n c t i o n of sleep s t i l l remains an enigma but i t i s recognized that sleep i s a b a s i c p h y s i o l o g i c a l need. Sleep de-p r i v a t i o n s t u d i e s have shoun the de t r i m e n t a l e f f e c t of l o s s of sleep over long periods of time. Houever,'patients i n postcardiotomy i n t e n s i v e care u n i t s f r e q u e n t l y complain of lac k of s l e e p . ^ P a t i e n t s have described ^JoAnna DeMeyer, "The Environment of the Int e n s i v e Care U n i t , " Nursing Forum 6 (October 1967): 262-72. 7 L. H.Nahum, "Madness i n the Recovery Room From Open-Heart Surgery or They Kept Waking Me Up," Connecticut Medicine 29 (November 1965): 771-72. [ their stay in these areas as a disturbing experience. They have especially noted the unusual sounds, the frightening atmosphere, 8 9 and the feeling of being physically restrained. ' The complaints of lack of sleep and the experiences des-cribed by patients uho have been in these areas should concern nurses. Nurses are responsible for helping the patient.meet his basic physiological need for sleep. Judgements about hou best to modify nursing care to meet this need are the responsibility of nurses uho uork in the postcardiotomy intensive care u n i t s . ^ Are patients continually interrupted? Hou much time is actually available to patients far rest and sleep? These are questions nurses should be able to ansuer in order to ensure patients are meeting their need for sleep. Assumptions of the Study The study uas based on the follouing assumptions: 1. Sleep is a basic physiological need. Therefore i f patients in the intensive care unit are constantly being interrupted they u i l l not have enough time available to meet their physiological need for sleep. Q Lazarus, "Prevention of Psychosis," p. 1190. g hornfeld, "Psychiatric Complications," p. 237. "^Elizabeth F. Pitorak, "Open-Ended Care for the Open-Heart Patient," American Journal of Nursing 69 (September 1969): 1896-99. 5 This assumption is based an Kleitman's statement that adults require eighty-five to ninety minutes to complete one sleep cycle and a representative night's sleep of about eight hours is likely to be made up of five such cycles.''"''' 2. There is a close resemblance betueen the psychosis of sleep deprivation and the description of postcardiotomy psychosis. This assumption is based on Kornfeld's finding that, The (postcardiotomy) psychosis...closely resembles the psychosis in sensory and sleep deprivation experiments. The progression from illusions to hallucinations to paranoid reactions is a typical sequence.12 Definition of Terms Interruption: used to refer to any stimulus uhich precip-itated patient activity or uhich increased the patient's auareness of his environment. Intensive Care Unit: used to refer to an area designed es-pecially for the care of the postcardiotomy patient. Limitations of the Study There uere recognized limitations to the study: 1. The highly specialized setting of the study limits the application of the results to a l l types of patient care areas. 2. Limitations imposed by uncontrolled variables included: "'""'"Nathaniel Kleitman, Sleep and Wakefulness (Chicago: University of Chicago Press, 1963), pp. 112-13. Donald S. Kornfeld, "Psychiatric Complications of Cardiac Surgery," International Psychiatric Clinics 4 (February 1967): 124. 6 a) the difference in medical orders regarding post-cardiotomy care. b) the differences in performance of the individual nurses uho uere providing patient care. c) the effect of the presence of the investigator upon the patient and the intensive care personnel. CHAPTER I I REVIEW DF THE LITERATURE In t r o d u c t i o n In reviewing the l i t e r a t u r e i t uas noted that the e t i o -l o g i c a l f a c t o r s of postoperative psychosis uere grouped under three main c a t e g o r i e s : (1) the preoperative p s y c h o l o g i c a l s t a t e of the i n d i v i d u a l , (2) the uniqueness of the i n t e n s i v e care u n i t e n v i r o n -ment, and (3) the p h y s i o l o g i c a l disturbances r e s u l t i n g from the s u r g i c a l procedure i t s e l f . * For the purpose of t h i s study i t uas decided to focus on the second e t i o l o g i c a l f a c t o r , the environment of the i n t e n s i v e care u n i t . The reason f o r t h i s focus i s the environment can be p a r t i a l l y c o n t r o l l e d by nursing personnel. The r e s u l t s of s e v e r a l s t u d i e s c a r r i e d out i n postcardiotomy i n t e n s i v e care u n i t s concluded that there uas a s i m i l a r i t y betueen the symptoms of postcardiotomy psy-chosis and sleep d e p r i v a t i o n . They also recommended that nursing procedures should be modified to provide.adequate sleep and to 2 3 maintain the day-auake, night-asleep r e l a t i o n s h i p . ' ^Herbert R. Lazarus and Jerome H. Hagens, Prevention of Psychosis F o l l o u i n g Open-Heart Surgery," American Journal of  P s y c h i a t r y 124 (March 1968): 76. 2 I b i d . , p. 80. "^Donald S. K o r n f e l d , Shelden Zimberg and James R. Malm, " P s y c h i a t r i c Complications of Open-Heart Surgery," The Neu England  Journal of Medicine 273 (August 1965): 291. 7 a For t h i s reason the l i t e r a t u r e reviewed for t h i s study focused on: (1) the 24-hour sleep-wakefulness c y c l e , (2) stages and patterns of s leep , (3) s leep depr i va t ion , (4) postcardiotomy psychosis , (5) the environment of the postcardiotomy intens ive care u n i t , and (6) re la ted nursing research . The 24-Hour Sleep-Wakefulness Cycle It was noted prev iously that studies by Lazarus and Kornfeld recommended that nursing procedures be modif ied to maintain the usual "day-awake" "n igh t -as leep" c y c l e s . What are these cyc les and how do they a f f e c t man? Man i s conscious of the many cyc les within nature that a f fec t h is l i f e , such as the seasons of the year or the phases of the moon. However, the one that exerts the greatest inf luence i s the day-night c y c l e . This theory i s supported in the fo l lowing statement by M i l l s : Most men are subjected throughout the i r l i v e s to an a l t e r a t i o n of l i g h t and darkness with an almost constant cycle length of 24 hours. This determines a pattern of behavior with a l te rna t ing periods of r e s t , a c t i v i t y , meals, etc 4 This 24-hour cyc le has been l a b e l l e d " c i r c a d i a n " from the Lat in word meaning "about a day." S c i e n t i s t s used t h i s term because the rhythms within the cyc le are not exact ly 24 hours but have a J . M i l l s , "Human C i rcadian Rhythms," P s y s i o l o q i c a l  Reviews 46 (January 1966): 129. 9 p e r i o d of approx imately 2k hours . The c i r c a d i a n rhythms appear to r e s u l t from tuo f a c t o r s : (1) an i n t e r n a l b i o l o g i c a l c l o c k , p o s s i b l y u i t h i n the hypothalmus, and (2) s y n c h r o n i z e r s i n the e x t e r n a l environment, of uh ich l i g h t and s o c i a l f a c t o r s are the most i m p o r t a n t . ^ The importance of these c i r c a d i a n rhythms i s becoming i n -c r e a s i n g l y recogn i zed because they appear to i n f l u e n c e many p h y s i o -l o g i c a l f u n c t i o n s of the human body. Some of the p h y s i o l o g i c a l parameters t h a t have shoun these rhythms and f u n c t i o n u i t h maximum and minimum per iods of a c t i v i t y a r e : metabo l i c r a t e , body temper-7 a t u r e , hear t r a t e , l e v e l of hormones, and r e n a l b lood f l o u . The most f a m i l i a r one i s body temperature because i t i s the e a s i e s t to measure. I t r i s e s and f a l l s u i t h c l o c k - l i k e r e g u l a r i t y each 2k hours . The l o u e s t body temperature occurs dur ing s l e e p and the g h ighest dur ing the time a person i s more a c t i v e or a l e r t s Man and h i s environment are i n constant i n t e r a c t i o n u i t h each o t h e r . Menaker s t a t e s : . Organisms are not pass i ve responders . They have i n t e r n a l accurate t ime-measur ing systems or ' c l o c k s ' . The e n v i r o n -5 N a t h a n i e l H l e i t m a n , P S l e e p and Wakefulness (Ch icago : U n i v e r s i t y of Chicago P r e s s : 1963) , p. 132. ^R. T. Li. L. Conroy, " Jet T r a v e l and C i r c a d i a n Rhythms," Nurs ing Times 68 (March 1972) : 371 . 7 M i l l s , "Human C i r c a d i a n Rhythms," pp. 1 2 8 - 7 1 . g U. S . , Department of H e a l t h , Educat ion and W e l f a r e , Current  Research on Sleep and Dreams (Washington, D .C . : P u b l i c Heal th Se rv i ce P u b l i c a t i o n No. 1389, 1965) , p. 5 . i 10 ment acts on the organism to keep the clock set to correct time.9 Hou flexible are these 24-hour cycles? Studies have proven that although the daily pattern of rhythms varies from one indiv-idual to another, individuals, very rarely, can function on a cycle that is not approximately 24 hours long."*"^ Kleitman's famous ex-periment shoued that subjects in time can adjust to a 21-hour or 28-hour day. Houever, i f the timetable varies from the 24-hour day by three hours either uay most subjects cannot adjust. Also the younger subjects can adapt easier than the older ones."'""'" This experiment and others support the hypothesis about the biological clock that controls the rhythms of the body, that i t "runs on a 24-hour schedule, uhich can be altered only slightly 12 and only i f given time to adjust." Stages and Patterns of Sleep In recent years, research into the phenomenon of sleep has revealed that i t is not a single uniform state but a complex and dynamic one. The electroencephlogram has helped identify the differ-ences in brain activity betueen the sleeping and uaking state, and g Michael Menaker, "Biological Clocks," Bioscience 19 (August 1969): 681. •^U. S. Department of Health, Education and Uelfare, Current  Research on Sleep and Dreams, p. 5. ^Kleitman, Sleep and [Wakefulness, pp. 172-84. 12 Nicole Beland-Marchak, "Circadian Rhythms," Canadian Nurse 64 (December 1968): 41. 11 those activities that characterize the stages of sleep. The stages of sleep as outlined by Dement and Kleitman are the most widely accepted.*^ From E.E.G. readings they identified the five stages of sleep and stated that an individual progresses from Stage 1 to Stage 4 and moves progressively back up the stages to Stage 1. Rapid eye movement (REM) sleep is the stage when the person is ascending from Stage 2 to Stage 1 uhich is differen-tiated from descending Stage 1. This term is used because during this stage jerky, rapid eye movements can be seen beneath the closed eyelids of the sleeper."1"^ In the past there has been confusion uith the terminology used to describe the stages of sleep. Houever, today the acceptable standard terminology used is rapid eye movement (REM) and non rapid eye movement (NREM) and the latter is further subdivided into four numbered stages. In healthy adults a representative night's sleep of about eight hours is made up of approximately five of uhat Kleitman termed basic rest activity cycles, referred to as BRAC, that are about W. C. Dement and Kleitman, "Cyclic Variations in E.E.G. During Sleep and Their Relation to Eye Movements, Body Motility and Dreaming," Electroencephloqraphy and Cl i n i c a l Neuro-physiology 9 (November 1957): 673-90. 14 E. Aserinsky and N. Kleitman, "Tuo Types of Occular Motility Occurring in Sleep," Journal of Applied Physiology 8 (July 1955): 1-10. 15 Frank R. Freeman, Sleep Research; A C r i t i c a l Revieu ( I l l i n o i s : Charles C. Thomas, 1972), p. 4. 12 eighty-five to ninety minutes in length."^ It has also been hypoth-17 esized that these BRAC operate during the making hours as u e l l . A typical night's sleep in young adults has been described in a number of studies. It has been noted that i n i t i a l l y a person going to sleep descends from Stage 1 to Stage 2, to Stage 3 and to Stage 4 in that order. In Stage 1, the person may experience a floating sensation or dri f t i n g . His body muscles are relaxing. He can be easily auakened by a noise or spoken uord and i f auakened he may assert he has not been sleeping. This stage lasts only a feu minutes. As the person descends into Stage 2 he is more relaxed but he s t i l l auakens easily as in Stage 1. Houever, i f auakened at 18 this paint a person might feel he had been "indulging in reverie." In Stage 3 sleep a person's muscles become very relaxed, vital.signs decrease and he is mare d i f f i c u l t to auaken. A person is in deep sleep in Stage k. He is very relaxed and rarely moves-, i f he is auakened he u i l l respond very slouly. After about seventy minutes of predominately Stages 3 and k IMREM sleep, the f i r s t REM sleep occurs. In this stage, rapid eye movements.are seen, v i t a l signs become exceedingly variable and vivid dreaming takes place. After about ten to fifteen minutes of REM sleep a person u i l l descend "^Kleitman, Sleep and Uakefulness, p. 113. 17 Nathaniel Kleitman, "Basic Rest-Activity Cycle in Re-lation to Sleep and Uakefulness," Sleep; Physiology and Pathology ed. Anthony Kales (Philadelphia and Toronto: J. B. Lippincott Co., 1969), p. 37. U. S. Department of Health, Education and Uelfare, Current  Research on Sleep and Dreams, p. 11. 1 3 19 again to Stage k. As the night progresses the ratio of REM sleep increases. Studies show stage U: sleep occurs predominately during the f i r s t third of the night, and REM sleep predominates the f i n a l third of the night. About twenty to twenty-five percent of the total sleep of young adults is spent in REM sleep, 5 percent in stage 1 (IMREM), 5 0 percent in stage 2 , and 2 D percent in stages 3 and 4 combined.2'"' The pattern of sleep from night to night in a single indiv-idual remains relatively constant, although patterns vary from individual to individual. However, with increasing age a very slight decrease in REM percentage and a somewhat larger decline in IMREM, . 2 1 stage, may occur. In recent years the great interest in sleep research shown by scientists has led to the forming of many hypotheses to explain the function of the various stages of sleep. There have been several theories advanced especially in regard to REM and IMREM, stage k, sleep. It was hypothesized that the former was needed to deal with stressful experiences and the latter was required to provide a chance for rest and relaxation. However, more recent theories state that each stage is v i t a l and necessary. Our increasing knowledge about sleep seems to indicate that each stage serves different organismic functions and 1 9 Ibid., pp. 1 1 - 1 3 . 2 D R. J. Berger, "The Sleep and Dream Cycle," Sleep: Physiology and Pathology, p. 2 1 . 2 1 Freemon, Sleep Research, p. 1 1 . is therefore characterized by different clusters of physio-logical activities.22 The physiological changes that occur during sleep have been investigated by many researchers. IMREM, Stage k, sleep has been described as the 'quieter phases' of sleep. It is characterized by slau, steady heart and respiratory rates, louer blood pressure, absence of rapid eye movement, a decrease in muscular tonus and decrease in body temperature. In REM sleep there is a transitory increase in systolic blood pressure, heart rate, respiratory rate 23 2k and in tuitching movements of the muscles of face and limbs. ' Sleep Deprivation Despite the extended knouledge of the physiology, neuro-physiology, biochemistry and psychology of sleep the restorative function of sleep s t i l l remains an enigma. One approach to studying the function of sleep i s to examine uhat happens to an individual uho is deprived of sleep. There have been many studies carried out in the laboratory that look at uhat happens to individuals uho are deprived of sleep. These experiments have studied three main types of sleep depriv-ation: (1) total, (2) partial, and (3) d i f f e r e n t i a l . Studies of total and partial deprivation usually focus on the length of time 22 R. J. Berger, "Physiological Characteristics of Sleep," Sleep; Physiology and Pathology, p. 72. 2 3 I b i d . , pp. 68-79. 2k Fredrick H. Loury, "Recent Sleep and Dream Research: Clini c a l Implications," Canadian Medical Association Journal 102 (May 1970): 1069-77. 15 given to sleep. Differential sleep deprivation involves depriv-ation of any one of the stages of sleep. The results of studies on total sleep deprivation uere de-pendent upon the length of time subjects went without sleep. In subjects who were awake sixty hours, neurological examinations showed weakness of flexion of the neck, hand tremor, awkwardness, nystagmus, ptosis, dysarthria, poverty of fa c i a l movements, peculiar preoccupation with details especially those related to personal be-25 longings, short attention span and an apathetic appearance. After 100 to 120 hours without sleep subjects experienced visual distortions, such as halos around objects, which may progress to frank visual hallucinations. Also in some individuals paranoid ideation may become prominent. However, i t was found that subjects may ILry to conceal these psychotic symptoms, therefore they may easily be missed by the researcher. Neurological findings at this time included: slurring of speech, inability to concentrate, i n -creased sensitivity to pain, episodes of disorientation to time, 26 and immediate memory loss such as forgetting the task at hand. However, further studies have shown that these neurological changes associated with sleep loss are transitory and after one or two nights of recovery sleep there is a dramatic reversal of the 27 pattern of behavior. Recovery from these acute symptoms is 25 J . F. Sassin, "Neurological Findings Following Short Term Sleep Deprivation," Archives of Neurology 22 (January 1970): 54-56. 26 Louis J . west, "Psychopathology Produced by Sleep Depriv-ation," Sleep and Altered States of Consciousness (Baltimore: Williams & Uilkens Co., 1967), p. 537. 27 Sassin, "Neurological Findings," p. 56. 16 associated with increased total sleep time and a marked increase in the percentage of time spent in the different stages of sleep. It uas found that on the f i r s t recovery night time spent in IMREM sleep, especially stage 4, showed a marked increase. On the other hand, the percentage of REM sleep remained relatively the same on the f i r s t recovery night but increased significantly on the fallowing nights. This increase of time spent in these two stages of sleep is accompanied, by a decrease in the amount of IMREM stage 2 sleep. Therefore the stability of the basic ninety minute cycle is pre-28 served despite the increase in one of the stages of sleep. The research on differential deprivation involved depriving subjects of some particular stage of sleep, for example depriving the individual of REM sleep. Studies have shown that when REM sleep was deprived i t caused a decreased onset and heightened level of REM sleep on the following night. Other studies on deprivation of Stage 4 sleep revealed there was a decreased latency and increased amount of Stage 4 sleep when the subjects returned to normal sleep patterns. The stability of the normal sleep pattern from night to night and the results of these studies indicate that a constant per-29 centage of REM and IMREM, stage 4, sleep is needed each night. The vast amount of research into the function of sleep has revealed how l i t t l e we know. As Freeman states: 28 R. J. Berger and I. Oswald, "Effects of Sleep Deprivation on Behavior, Subsequent Sleep and Dreaming," Journal of Mental  Science 108 (April 1962): 457-65. 1 29 Uilse B. Webb, "Partial and Differential Sleep Deprivation," Sleep; Physiology and Pathology, pp. 221-31. i ....such a complex phenomenon as sleep probably has many f u n c t i o n s , some neurochemical, some psychologic, some ontogenic.30 Postcardiotomy Psychosis As s t a t e d i n chapter one the incidence of postoperative psychosis i s higher i n open-heart s u r g i c a l p a t i e n t s i n comparison to other s u r g i c a l patients."'''' Although there have been many f a c t o r s i d e n t i f i e d as c o n t r i b u t i n g to i t s occurrence, there i s l i t t l e agree-ment about the cause. Abram i d e n t i f i e d such f a c t o r s as degree of preoperative a n x i e t y , the use of d e n i a l as a defense mechanism and the fear of death as s i g n i f i c a n t i n the development of psychosis 32 a f t e r open-heart surgery. Other f a c t o r s that may c o n t r i b u t e to i t s development are: age, s e v e r i t y of preoperative i l l n e s s , length and complexity of the operative procedure, time on cardiopulmonary bypass, sex, and length af stay i n i n t e n s i v e care unit." 5'' Lazarus and K a r n f e l d looked at the s i m i l a r i t y betueen the 34 35 symptoms of postcardiotomy psychosis and sleep d e p r i v a t i o n . ' ""Vreemon, Sleep Research, p. 160. "'"''Chase P. K i m b a l l , " P s y c h o l o g i c a l Responses to Open-Heart Surgery," AORIM 12 (February 1970): 73. 32 Harry S. Abram, "Adaptation to Open-Heart Surgery: A P s y c h i a t r i c Study to the Threat of Death," The American Journal of  P s y c h i a t r y 122 (December 1965): 659-67. "'"'p. H. Blachy and A l b e r t S t a r r , "Post-Cardiotomy Delerium," American Journal of P s y c h i a t r y 121 (October 1964): 371-75. 34 H. R. Lazarus and J . H. Hagens, "Prevention of Psychosis F o l l o u i n g Open-Heart Surgery," American Journal of P s y c h i a t r y 124 (March 1968): 1190-95. 35 Donald S. K o r n f e l d , " P s y c h i a t r i c Complications of Cardiac Surgery," I n t e r n a t i o n a l P s y c h i a t r i c C l i n i c s 4 (February 1967): 115-31 These symptoms included the follouing behaviors: acute excitement, disorientation, confusion, depression, i l l u s i o n , hallucinations, and paranoid behavior. Also, another similarity betueen the tuo uas seen in the time sequence. Kornfeld noted that the description of the f i f t h day turning point in sleep deprivation studies uhen flagrant psychotic symptoms appear, closely parallel the c l i n i c a l experience in bath time af onset and rapid clearing uith adequate sleep. Environment of the Postcardiotomy Intensive Care Unit The environment of the intensive care unit is one of the factors that contributes to postoperative psychosis in open-heart patients." 5^ DeMeyer intervieued tuenty-four cardiac surgical patients to document their perception of their experience in the intensive care unit. These patients spoke of the number of people uho examined them or checked the equipment attached to them, the people uho talked about them uithout including them in the convers-37 ation, and a general sense of urgency in the environment. •ther studies have supported these findings, that the stay in the intensive care unit is a very disturbing experience. The en-vironment is described as one uhere patients are kept close to each other only separated by curtains and they are chained doun by uires "^Ibid., p. 115. 37 JoAnna DeMeyer, "The Environment of the Intensive Care Unit," Nursing Forum k (October 1967): 263. 19 attached to electrodes. Also,there are constant and unusual sounds, for example, the hissing of oxygen and the endless clicking of monitors. They concluded that environmental factors made prolonged uninterrupted sleep impossible for the adult in the open-heart intensive care unit." 5^ Another study at Temple University looked at interruptions sustained by these patients. They stated the biggest deterent to sleep uas the number of interruptions by nurses and physicians. They found that a l l patients suffer from some degree of sleep deprivation, 39 sensory over-stimulation and human isolation. These patients are c r i t i c a l l y i l l and do need constant ob-servation follouing open-heart surgery. Pitroak and Rae describe the kind and type of nursing care that must be carried out during this period. Houever, they recommend along uith Kornfeld, Lazarus and DeMeyer, that nursing procedures be geared to provide adequate sleep and rest, and to maintain the day-auake, night-sleep relation-.. 40,41 ship. ' 38 L. H. IMahum, "Madness in the Recovery Room From Open-Heart Surgery or They Kept LJaking Me Up," Connecticut Medicine 29 (November 1965): 771. 39 "Intensive Care Gives Patients L i t t l e Rest," Journal  American Medical Association 210 (December 1969): 1682. 40 Elizabeth Pitorak,"Alleviating Cardiac Patients' Fear Important Part of Nurses' Role," Hospital Topics 44 (May 1966): 127. 41 Nancy Mara Rae, "Caring for Patients Follouing Open-Heart Surgery," American Journal of Nursing 63 (November 1963): 77-82. 2D Existing Nursing Research Several nurse researchers have carried cut studies cn sleep deprivation follouing open-heart surgery. Three studies have been conducted at the University of [Washington. Eluell, in 1967, studied duration of interruptions uhich initiated activity and the relation-ship betueen their duration, the actual amount of sleep obtained, and the time available for sleep for four subjects 11:00 P.M. to 7:00 A.M. on their f i r s t , second and third nights follouing surgery. In 196S, McFadden observed four postcardiotomy subjects on their fourth to sixth postoperative nights to determine i f they uere de-prived of sleep. Both investigators found indications of sleep de-privation in their subjects. The third study, in 1969, uas carried out by three investigators, Garner, Hickman and Fugate. They ob-served four subjects for tuenty-four hours over eight postoperative days. In addition, they looked at the number, frequency and char-acter of potential interruptions. The results shoued signs of sleep deprivation in their subjects. In 1972, Walker documented the interactions sustained by four cardiotomy patients in the intensive care unit during an eight hour period for three consecutive days. Her study revealed a very high number of interactions for each patient. Summary This chapter focused on the environment of the intensive care unit as one of the three main factors that contribute to postoper-ative psychosis. It uas noted that there uas a similarity betueen 21 the symptoms of sleep deprivation and postcardiotomy psychosis by several researchers. Also, several studies recommended the maintenance of the tuenty-four hour sleep uakefulness cycle in patients uho are nursed in these areas. The literature revieu focused on the follouing: (1) the 24-hour sleep-uakefulness cycle, (2) stages and patterns of sleep, (3) sleep deprivation, (4) post-cardiotomy psychosis, and (5) the environment of the open-heart in-tensive care unit. Researchers had noted that interruptions by doctors and nurses uere the biggest deterrent to sleep. In revieuing existing research there appeared to be a lack of available studies on the type and frequency of interruptions experienced by patients in postcardiotomy intensive care units. CHAPTER III METHODOLOGY Introduction This study uas designed as a descriptive survey to collect data on the type and frequency of interruptions sustained by post-cardiotomy patients in an intensive care unit. In this chapter the follouing u i l l be discussed: adaptation and content of the tool, the setting and patient care activities of the intensive care unit, the pilot study, the sample and method of collecting data. Adaptation of the Tool The farm used in this survey uas a checklist of interrupting a c t i v i t i e s . It uas adapted from the one used by Garner in her study. Adaptation uas accomplished by revieuing the.form in the light of pertinent information found in the literature, u t i l i z i n g the routine nursing care procedures of the hospital setting uhere the study uas carried out, having the form revieued by senior nurses uho uark in a postcardiotomy intensive care unit and then by testing the form during the pilot study. The result of these procedures indicated the tool had content validity. Checklist of Interrupting Activities The checklist of interrupting activities used for collecting the data is found in Appendix A. Bath the content and the order of 22 23 the checklist underwent change from the form used by Garner. The changes were made to add items that mere pertinent to the purpose of the study and to delete ones that uere not. A change in the order of activities uas made for practicality and ease of use. Also, because continuous observations uere pertinent to the study a different format uas used. At the top of the form a space uas provided to note the date, time and postoperative day of the patient. To f a c i l i t a t e the analysis of the data the types of activ-i t i e s uere organized under four categories (Appendix B, page 55 ): 1. Nursing activities included any interruptions by a nurse in giving care either in direct contact or indirect contact uith the patient. These activities uere grouped according to the kind of nursing care; that i s : (a) measures to provide comfort, (b) mon-itoring measures, (c) measures to support respiration, (d) circu-lation, (e) nutrition and elimination, and (f) nurse communicating uith patient. The latter refers to interruptions initiated by the nurse talking directly to the patient uhen no other activity uas apparent. 2. Patient initiated activities included any interruptions that uere initiated by the patient, uithout any other apparent provoking stimulus. 3. Activities of others included any interruptions by any individual other than a nurse. U. Environmental activities included any interruption by an individual or thing not related to the care of the patient. 2k The Setting The setting in uhich the study took place uas the past-cardiatDmy intensive care unit of a 2,000 bed hospital. The inten-sive care unit uhich can accommodate tuelve patients consists of one area uith ten patient care units and another area u i t h tuo patient care units. The area containing the ten units provided the setting in uhich the observations uere made. This area is rectangular in shape uith a jog at one end. There are doors at each end and tuo doors that open into a corridor uhich runs along the length of one side of the unit. The unit is partitioned off u i t h six patient care units on one side and four patient care units on the other side of the partition. There are tuo nursing stations, one at each end of the unit. The main station is at the end of the area u i t h the six care units. At the other end just off from the nurses' station uas a dirty u t i l i t y area u i t h a hopper sink. Eight patient care units are side by side and face a rou of windows. The other tuo care units are in the area of the jog and face in the apposite direction ta-uards the main nurses' station. Each care unit is approximately four feet from the adjoining one. Every unit has a monitor over the head of the bed, under uhich a Mark UII Bird Respirator is mounted on the u a l l . Also mounted on the u a l l is a sphygmomanometer. An intravenous pole on a track is on the ceiling directly over the patient's bed. There are four drawers for supplies and patients' belongings built into the u a l l for each unit. Also, oxygen, suction and compressed air outlets and underuater chest suction are part of the individual patient 25 units. The unit is a neutral color uith uhite walls and ceiling, gold curtains betueen care units and a tan floor. The nurses uear uhite uniforms. Light for the patient care areas is provided by a large, set-in, ceiling light, the intensity of uhich uas varied independently for each unit. Additional light comes from the nurses' station and u t i l i t y area. Patient Care Activities Since the number of interruptions depended partly ,on the nursing care these patients received, the usual routines u i l l be briefly described. •n the operative day and then as long as their condition dic-tated, postcardiotomy patients uere the sole responsibility of one registered nurse. Uhen their condition improved the patients shared a nurse uith one or more other patients. The immediate postoperative care of these patients included a v i t a l signs check every five minutes for several readings on ad-mission to the area. After the f i r s t readings the v i t a l signs uere checked every fifteen minutes until stable, then every thirty min-utes for the f i r s t eight hours. Then they uere reduced to every hour and after thirty-six hours they uere taken every tuo hours. The temperature uas taken every fifteen to thirty minutes until normal, and then every tuo hours. Also, an hourly central venous pressure uas taken and a head to toe check three times a shift, uhich included: pupils, limb movement, level of consciousness, color, chest expansion, breath sounds, abdomen and pedal pulses. Other activities included: hourly stripping of chest tubes, nasotracheal suctioning, measuring urine output and any additional care or therapy indicated by the patient's condition. Continuous oxygen by mask uas given for the f i r s t three postoperative days. As the patient progressed the amount of care uas adjusted accord-ingly. Specimens for blood gases, hemoglobin and serum electro-lytes and a chest x-ray uere taken on return from the operating room and every morning for the f i r s t three postoperative days. E.C.G. tracings uere taken on admission to the intensive care unit after surgery and then once a shift for forty-eight hours and then as necessary. The patient usually returned from the operating room uith an endotracheal tube, an intravenous catheter, arterial catheter, central venous pressure line, tuo chest tubes and a Foley catheter. Each one of the tubes is removed as soon as possible. The Pilot Study To test the adapted observational tool, to check for prac-t i c a l i t y and ease of use of the tool, to check observer r e l i a b i l i t y , to determine the best location for the observer to carry out her study and to determine the fea s i b i l i t y of observing continuously for a period of time, a tuo-hour pilot study uas conducted by the observer and another master's student in nursing. The time chosen uas a period from 9:00 A.M. to 11:DD A.M. It uas f e l t that this uould be a time uhen many activities uould.be occurring. The results of the pilot study uere as follous. In the f i r s t half hour of the tuo-hour pilot study there uas 95 percent agreement betueen the observers regarding the types of interruptions. 27 Uith regards to the frequency of interruptions the results of one observer uas six minutes of no interruptions, uhereas the second observer noted eight.minutes of no interruptions. Houever, the last hour and one-half there uas 100 percent agreement betueen the observers both in the types and frequency of interruptions. It uas f e l t by the tuo observers that the discrepancy in the results of the f i r s t thirty minutes of observation may have been due to the observers' unfamiliarity uith the checklist i t s e l f . The results of the Pilot Study indicated that i t uas feasible to observe for a four-hour period and that there uere feu intra-observer differences in the recording. The Sample The sample included 108 hours of observation uhich uere divided into tuenty-seven four-hour blocks. The four-hour blacks uere: 2:00 P.M. - 6.00 P.M., 6:00 P.M. - 10:00 P.M., 10:00 P.M. -2:00 A.M., 2:00 A.M. - 6.00 A.M., 6:00 A.M. - 10:00 A.M., and 10:00 A.M. - 2:00 P.M. These time blocks uere chosen because most patients returned from the operating roam betueen 12:00 M. and 2:00 P.M. It uas decided that the observation for the f i r s t past-operative period could begin at 2:00 P.M. The time postoperatively uas also taken into consideration because of the change in patients' condition in the f i r s t feu days. It uas decided to look at post-operative time in an early period, zero to sixteen hours, a middle period, sixteen to thirty-six hours, and a late period, thirty-six to f i f t y - s i x hours. In each postoperative period there uere thirty-six hours of observations. A random sampling of the four-hour time blocks in each postoperative period over the days of the ueek uas 28 carried cut and can be seen in Appendix C, page 57 . Adult patients uho had surgery uhere the cardiopulmonary bypass machine uas used uere observed. Children uere eliminated from the study because the incidence of postoperative psychosis is rare in their cases.* Collection of the Data Before beginning the study a resume of the study uas sent to the Acting Director of IMursing via the liaison person betueen the university and the hospital. The investigator received uritten permission to carry out the study. The unit supervisor uas contacted and she put the investigator in touch uith the head nurse of the postcardiotomy intensive care unit. IMurses uorking in the area uere informed about the purpose of the study at a staff meeting. Also individual nurses caring for patients being observed uere asked at each observation time i f they uould object to the investigator observing their patient. The Human Rights Committee at the University uere also sent a resume of the study. As the study did not f a l l under the jur i s -diction of this committee, the investigator could begin her observ-ations. Permission from individual patients uas not obtained because there uas no invasion of the patient's privacy or risk involved. Also, no record of names uas kept and the routine care uas not *Donald S. Kornfeld, Sheldon Zimberg, and James R. Malm, "Psychiatric Complications of Open-Heart Surgery," The IMeu England  Journal of Medicine 273 (August 1965): 292. 2 9 a l t e r e d i n any uay. A l l o b s e r v a t i o n s o v e r the 108 hours uere r e c o r d e d by the i n v e s t i g a t o r . The i n v e s t i g a t o r a r r i v e d a t the a r e a a p p r o x i m a t e l y te n minutes b e f o r e t h e hour the o b s e r v a t i o n s uere to b e g i n . T h i s gave her time t o s e l e c t t h e p a t i e n t uho uas to be o b s e r v e d , t h a t i s , the p a t i e n t uho uas i n the p a r t i c u l a r p o s t o p e r a t i v e time p e r i o d o f the sample. The i n v e s t i g a t o r s t a t i o n e d h e r s e l f uhere she uas a b l e to v i e u the p a t i e n t w i t h o u t i n t e r f e r i n g u i t h c a r e . The d e s i g n o f the u n i t made i t i m p o s s i b l e f o r the o b s e r v e r t o be out o f the l i n e o f v i s i o n o f the p a t i e n t . A u a t c h u i t h a second hand was used f o r the minute by minute o b s e r v a t i o n and was s e t at the same time as the c l o c k i n the u n i t . The o b s e r v a t i o n began as the second hand was at the t u e l v e o ' c l o c k mark o f the f i r s t minute o f the f i r s t h o ur. Each o b s e r v a t i o n uas r e c o r d e d on the c h e c k l i s t o f a c t i v i t i e s f o r every minute over the r f o u r - h o u r p e r i o d . The o b s e r v a t i o n p e r i o d ended uhen the second hand re a c h e d t h e t u e l v e o ' c l o c k mark o f the f i r s t minute o f the b e g i n n i n g of the f i f t h h o ur. A l l o b s e r v a t i o n s uere completed i n a s i x - u e e k p e r i o d . Summary T h i s c h a p t e r has p r e s e n t e d the methodology o f the s t u d y u h i c h i n c l u d e d : the a d a p t a t i o n and c o n t e n t o f the t o o l , a d e s c r i p t i o n o f the s e t t i n g and p a t i e n t c a r e a c t i v i t i e s o f the p o s t c a r d i o t o m y i n -t e n s i v e c a r e u n i t , a resume o f the p i l o t s t u d y , the sample and the method o f d a t a c o l l e c t i o n . i CHAPTER IV ANALYSIS DF THE DATA Presented in this chapter are the data obtained by the method described in Chapter III. Answers were sought to the following questions: 1. How frequent are the interruptions experienced by these patients? 2. How long are the blocks of uninterrupted time? 3. Uhat are the types of interruptions? Presentation of Findings Frequency of Interruptions Table 1 indicates the average time between interruptions in the four hour blocks within the three postoperative periods. The early postoperative period had the longest average time between interruptions, that i s , one interruption occurring every 2.43 minutes. In the mid and late postoperative period the average times between interruptions were almost identical, 1.97 and 1.95 minutes respectively. However, the greatest average time between interruptions in the four hour time blocks was between 2:00 A.M. to 6:00 A.M., 3.02 minutes in the early postoperative period and 3.33 minutes in the late postoperative period. The lowest average time between inter-30 31 TABLE 1 AVERAGE TIME IN MINUTES BETWEEN INTERRUPTIONS IN THE FOUR-HOUR TIME BLOCKS IN EACH POSTOPERATIVE PERIOD Average Time in Minutes Betueen Interruptions Time Blocks Early Postoperative Period Mid Postoperative Period Late Postoperative Period 2-6 P.M. 2.65 1.47 1.38 6-10 P.M. 2.00 1.60 1.63 10-2 A.M. 2.OS 2.65 • • • 2-6 A.M. 3.02 • • • 3.33 6-10 A.M. a • • • 1.94 2.01 10-2 P.M. • • • 2.18 1.40 Period Average 2.43 1 .97 1.95 No observations made. ruptions uas 1.38 minutes in the late postoperative period betueen 2:00 P.M. and 6:00 P.M. Length of the Blocks of Uninterrupted Time Findings relevant to the second question regarding the length of the uninterrupted time blocks are shoun in Table 2. The data reveal that there are no uninterrupted time blocks of over f i f t y minutes in any postoperative period. The early postoperative period has tuo uninterrupted time blocks of forty-one to f i f t y minutes in length. In the mid and late postoperative periods the longest blocks 32 TABLE 2 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN THE THREE POSTOPERATIVE PERIODS Number of Uninterrupted Time Blocks Duration Early Postoperative Period Mid Postoperative Period Late Postoperative Period Total 5 mins. or less 213 181 185 579 6 to 10 mins. 36 26 . 27 89 11 to 20 mins. 14 21 . 14 49 21 to 30 mins. 7 3 3 13 31 to 40 mins. 1 2 1 . 4. 41 to 50 mins. 2 0 0 2 over 50 mins. 0 0 0 0 of uninterrupted time uere thirty-one to forty minutes. The greatest total number of uninterrupted time blocks in a l l three postoperative periods uere five minutes or less in length. The average number and length of uninterrupted time blocks in each four-hour time block are shoun in Table 3. Averages uere computed for this table because there uere unequal numbers of the four-hour blacks in the three postoperative periods. The total number and duration of uninterrupted time blocks for a l l the four-hour time blocks are shoun in Appendix D. The shortest uninterrupted time blocks uere betueen 2:00 P.M. and 6:00 P.M. in the mid post-operative period, uith no blocks longer than ten minutes. 33 TABLE 3 AVERAGE NUMBER AND DURATION OF THE UNINTERRUPTED TIME BLOCKS IN THE FOUR-HOUR BLOCKS IN THE THREE POSTOPERATIVE PERIODS Duration Average Number of Uninterrupted Time Blocks Four Hour Time Blocks 2-6 6-lD 10-2 2-6 6-10 10-2 P.M. P.M. A.M. A.M. A.M. P.M. Early Postoperative Period 5 mins. or less 25.0 25.D 24.3 2D.0 a 6 to 10 mins. 4.5 4.D 3.3 4.D 11 to 20 mins. l.D 2.0 .66 3 ... 21 to 3D mins. 1.0 .5 l.D .5 31 to 40 mins. D 0 D .5 ... 41 to 50 mins. .5 D .33 D • • • • • • aver 50 mins. D 0 D 0 ... ... Mid Postoperative Period 5 mins. or less 29.D 22.5 19.5 18.5 15.5 6 to 10 mins. 3.D .5 4.5 • • • 2.D 4.5 11 to 2D mins. 0 1.0 3.5 • • o 2.5 3.5 21 to 30 mins. D 1.0 .5 • mo D D 31 to 40 mins. D D D • • • l.D D 41 to 50 mins. D D 0 • • • 0 D over 50 mins. 0 0 D ... D D Late Postoperative Period 5 mins. or less 16.D 22.33 ... 15.D 21.0 23.0 6 to 10 mins. 2.D 3.33 ... 5.D 3.D 2.D 11 to 2D mins. l.D 1.33 ... 2.D 4.D 1.0 21 to 30 mins. .5 D ... 2.D D D 31 to 4D mins. .5 D ... D D D 41 to 5D mins. 0 D ... D D 0 Dver 5D mins. 0 D ... D D D No observations made. 34 Types of Interruptions Tables 4 and 5 show the types of interruptions in each of the three postoperative periods. The data in Table 4 reveal that the total number of inter-ruptions increases over the three postoperative periods. The greatest total number of interruptions in a l l three periods uas the result of nursing a c t i v i t i e s . Environmental interruptions uere the second highest, with the greatest frequency in the mid postoperative period. TABLE 4 NUMBER AND PERCENTAGE OF INTERRUPTIONS IN EACH CATEGORY UITHIN THE THREE POSTOPERATIVE PERIODS Number and Percentage of Interruptions Category Early Postoperative Period Mid Postoperative Period Late Postoperative Period No. % No. % No. % Nursing activities 644 58 568 43 769 50 Patient initiated activities 126 11 135 10 233 15 Activities of others 102 9 283 22 269 17 Environment 24S 22 334 25 262 18 Total 1,120" 100 1,320 100 1,533 100 35 TABLE 5 NUMBER QF INTERRUPTIONS IN THE TYPES OF ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Number of Interruptions Types of Early Mid Late Activities Postoperative Postoperative Postoperative Period Period Period Nursing activities Comfort measures 139 195 270 Monitoring measures 226 166 216 Circulation measures 74 68 76 Respiration measures . 12S 55 50 Nutrition and elimination measures 12 48 105 Nurse communicat-ing uith patient 65 36 52 Total Gkk 568 769 Patient initiated activities 126 135 233 Activities of others Personal visitors 26 38 41 Doctor 16 20 4 Housekeeping • • • 2 4 Laboratory 5 5 38 X-ray. 7 10 5 Physiotherapist ka 208 177 Total 102 283 269 Environment Noise 109 144 109 Lights 6 5 2 Telephone 11 10 14 Talking 115 163 129 Monitor 1 alarm 7 12 8 Total ZkB 334 262 I 36 Tables 6 to 8 contain a further breakdown of the types of interrupting a c t i v i t i e s . Each category in these tables is represented as 100 percent and the types of activities were calculated as a per-centage of the tot a l . Data from Table 6 show the percentage of interruptions by types of nursing ac t i v i t i e s . In the three postoperative periods comfort and monitoring were responsible for over 55 percent of the interruptions. The percentage of interruptions by others is indicated in Table 7. In a l l three postoperative periods the physiotherapist was responsible for the greatest number of interruptions. However, types of interruptions by others were only responsible for 9 percent, 22 percent and 17 percent of the total number of interruptions in the early, mid and late postoperative periods respectively (see Table 4). Environmental interruptions as shown in Table 8 reveal that noise and talking were responsible for over 90 percent of these inter-ruptions in a l l three postoperative periods. As indicated in Table 1 environmental factors were the second most frequent type of inter-ruption. The data in Table 9 show the average number of interruptions in the four categories of activity for the different times of day. IMursing activities increased over the postoperative period between 2:00 P.M. to 6:00 P.M. However, in the 10:00 P.M. to 2:00 A.M. and the 2:00 A.M. to 6:00 A.M. time blocks, nursing activities decreased as postoperative time increased. Patient initiated activities i n -creased over the postoperative period. This increase is what would be expected in a normal.postoperative recovery course. Environmental 37 TABLE 6 PERCENTAGE OF INTERRUPTIONS BY TYPES OF NURSING ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Types of Percentage of Interruptions Nursing Activities Early Postoperative Period Mid Postoperative Period Late Postoperative Period Comfort measures 21.5 34 35 Monitoring 35 29 28 Circulation 11.5 12 10 Respiration 20 10 6.5 Nutrition and Elimination 2 9 14 Nurse Communicating uith Patient 10 6 6.5 Total 100 100 100 TABLE 7 PERCENTAGE OF INTERRUPTIONS BY ACTIVITIES OF IN THE THREE POSTOPERATIVE PERIODS~ OTHERS Activities Percentage of Interruptions of Others Early Postoperative Period Mid Postoperative Period Late Postoperative Period Personal visitors 25 13 15 Doctor 16 7 1.5 Housekeeping 0 1 1.5 Laboratory 5 2 14 X-ray •7 4 2 Physiotherapist un 73 66 Total 100 100 100 38 TABLE 8 PERCENTAGE DF INTERRUPTIONS BY ENVIRONMENTAL ACTIVITIES IN THE THREE POSTOPERATIVE PERIODS Percentage of Interruptions Environment Early Postoperative Period Mid Postoperative Period Late Postoperative Period Noise 44 43 42 Lights 2.5 1.5 1 Telephone 4.5 3 5 Talking 46 49 49 Monitor alarm 3 3.5 2 Total 100 100 100 39 TABLE 9 AVERAGE NUMBER DF INTERRUPTIONS IN THE CATEGORIES OF ACTIVITY IN THE FOUR-HOUR BLOCKS IN THE THREE POSTOPERATIVE PERIODS Average Number of Interruptions Category Four -Hour Blocks of 2-6 6-10 10-2 2 -6 6 -10 10-2 Activity P.M. P.M. A.M. A.M. A.M. P.M. Early Postoperative Period Nursing 7 1 . 5 8 0 . 5 75 5 7 . 5 a • • • • • • Patient Initiated 10 8 14.6 23 • • • • • • Others 19.5 28 1.6 1 • • • • • • Environment 6 . 5 23 57 .6 a • • • • • •• Mid Postoperative Period Nursing B9 108.5 3 6 . 5 • • • 5 5 . 5 38 Patient 7 5 . 5 26 • • • 11 2 1 . 5 Others 52 5 2 0 . 5 • • • 40.5 49.5 Environment 43 57 28 • • • 40 2 1 . 5 Late Postoperative Period Nursing 121 8 8 . 6 • • • 37 52 93 Patient Initiated 2 3 . 5 18.6 • • * 49 20 30 .5 Others 37 21 .6 • • • 1 40 37 .5 Environment 11 43.6 • • • 10 29 °35 No observations made. 40 interruptions uere the highest in most of the time blocks in the mid postoperative period. Discussion of the Findings The findings that emerged as significant in this study uere: (1) that patients in postcardiotomy intensive care units uere inter-rupted so frequently that there uas l i t t l e time available for rest and sleep, and (2) nursing care activities uere responsible far the greatest number of these interruptions. These findings were similar to the findings of other studies carried out in postcardiotomy intensive care units by Kornfeld and Lazarus. Patients can not sleep i f they are constantly interrupted. The data in Table 1 demonstrate that the frequency of interruptions in a l l time blocks over the three postoperative periods was high. The range for the total postoperative period was from one interruption occurring every 1.40 minutes to one interruption occurring every 3.33 minutes. The frequency of interruptions noted in this study seemed to reflect the tendency of postcardiotomy intensive care units to provide continued care without regard to time of day and the 24-hour sleep-wakefulness cycle. In order to complete one sleep cycle an adult requires approx-imately eighty-five to ninety minutes of uninterrupted rest."'' The data in Table 2 reveal there are no uninterrupted time blacks over f i f t y minutes in any of the postoperative periods. These findings "''Nathaniel Kleitman, Sleep and wakefulness (Chicago: University of Chicago Press, 1963), p. 91. indicated that there uas no time available to patients far periods of prolonged, uninterrupted rest. Therefore, patients in the f i r s t f i f t y - s i x hours postoperatively uere unable to complete one sleep cycle because of the constant interruptions. Also, the data suggested that patients uere totally de-prived of REM sleep. As noted previously, in Chapter 2, REM sleep is the stage uhen a person is ascending from Stage 2 to Stage 1. This stage of sleep occurs approximately after seventy minutes of sleep. As mentioned in the literature revieu each stage of sleep is v i t a l and necessary. These findings suggested that patients uere not meeting their physiological need for sleep in the f i r s t f i f t y -six hours postoperative in a postcardiotomy intensive care unit. Three studies from the University of Washington by Elue l l , McFaddin and Garner found that patients in an intensive care unit follouing open-heart surgery uere deprived of sleep. Studies have indicated that intensive nursing and medical care is the biggest deterrent to sleep in the open-heart intensive care 2 unit. The data in Table H support these findings. Nursing activ-i t i e s uere the most frequent source of interruptions for a l l three postoperative periods. The next most frequent activities uere environmental. Talking among the hospital personnel and noise together total 90 percent of these interruptions. Although i t uas beyond the scope of this study to document in detail the cause of the noise the investigator 2 Donald S. Kornfeld, Shelden Zimberg, and James R. Malm, "Psychiatric Complications of Open-Heart Surgery," The Neu England  Journal of Medicine 273 (August 1965): 291. 42 did note some of the specific noises. These included such things as: respirators clicking, hoppers flushing, blinds snapping, addressograph banging* pounding battle on the floor, restocking drawers, emptying garbage pails, whistling of housekeepers and doors slamming. By controlling these environmental interruptions the total number of interruptions might be decreased on an average by 22 percent. As noted earlier in Chapter 1, postcardiotomy patients complained of the noisy environment of the intensive care unit. Summary This chapter presented the findings of the study and °the discussion of those findings. The data were analyzed in the light of the three questions posed in the statement of the problem. o CHAPTER V SUMMARY, IMPLICATIONS AND RECOMMENDATIONS FOR NURSING CARE, AND RECOMMENDATIONS FOR FURTHER INVESTIGATION Summary The incidence of postoperative psychosis follouing open-heart surgery, as reported in the literature, is quite high. One of the possible contributing factors uhich has been cited is the environment of the intensive care unit. Postcardiotomy patients have complained about the noisy atmosphere and the lack of sleep during their stay in the intensive care unit. Several researchers have noted the similarity betueen those symptoms of sleep depriv-ation and postcardiotomy psychosis. The biggest deterrent to sleep in the postcardiotomy intensive care unit is attributed to the number of interruptions by nursing and medical personnel. The purpose of this study uas to document the type and frequency of interruptions sustained by postcardiotomy patients in an intensive care unit. To accomplish this, the data uere collected by the investigator u t i l i z i n g a non-participant checklist of inter-rupting a c t i v i t i e s . The sample included 108 hours of observation covering the f i r s t f i f t y - s i x postoperative hours, divided into early, mid and late postoperative periods. In each postoperative period there uere thirty-six hours of observation. To f a c i l i t a t e contin-uous observation the observation periods uere divided into four-43 4 4 hour blocks, for example, 2:00 P.M. to 6:00 P.M. A random samp-ling of the four-hour blocks in each postoperative period over the days of the ueek uas carried out to ensure unbiased selection. A revieu of the literature focused on the environment of the postcardiotomy intensive care unit uhich is considered to be one etiological factor of postcardiotomy psychosis. A descriptive analysis of the data collected centered around the three questions posed in the statement of the problem. The questions related to the length of the uninterrupted time blocks and the frequency and types of interruptions. In order to f a c i l i -tate the analysis of the data the types of interruptions uere organized into four main categories: (1) nursing activities, (2) patient initiated a c t i v i t i e s , (3) activities of others, and ( 4 ) environment. The data regarding the frequency of interruptions indicate the total average time betueen interruptions is 2.12 minutes for the entire observation period. Also, the greatest length of aver-age time betueen interruptions is only 3.33 minutes, recorded be-tueen 2:00 A.M. and 6:00 A.M. in the late postoperative period. There are no uninterrupted time blacks over f i f t y minutes in the three postoperative periods. In the total observation there are tuo blocks of uninterrupted time, forty to f i f t y minutes long. Houever, both of these blocks occur during the day. The data show, that the number of interruptions increased from the early postoperative period to the late postoperative period from 1,120 to 1,533. IMursing activities constituted the highest number of interruptions. Percentage of the total number of 45 interruptions in each category for the IDS hours of observation is shoun as fallows: Category af Interruptions Percentage IMursing Activities 50 Patient Initiated Activities 12 Activities of Others 16 Environment 22 The conclusions that can be made from these findings are that patients in the postcardiotomy intensive care unit are frequently interrupted and there is very l i t t l e time available for rest and sleep. Implications and Recommendations  for IMursing Care Nurses have the responsibility for helping patients meet their physiological need for sleep. Also, several studies have recommended that nurses in postcardiotomy intensive care units re-organize their care to maintain the patient's day-awake and night-asleep cycle. Intensive care nursing requires that the patients be interrupted more than patients who are not in intensive care units. Houever, nurses should be able to provide adequate care in these areas and s t i l l help the patient meet his individual sleep need by reducing the number of interruptions. Some recommendations to implement this aspect of care are: 1. Nursing care plans in intensive care units should in-corporate the patient's need for sleep. 2. Nursing histories should include the patient's sleep 46 pattern to maintain the usual day-awake and night-asleep cycle. 3. Reorganization of routine nursing procedures such as v i t a l signs to allow for a maximum amount of uninterrupted time for rest and sleep. 4. Nurses should educate other hospital personnel to the patient's need for sleep and include them in planning care to allow for maximum rest periods. 5. Nurses should be aware of the impact of environmental stimuli on the completion of the sleep cycle and their role in con-trolling them. Recommendations for Further Investigation The findings of this study suggest other studies which might be carried out: 1. A similar study might be designed u t i l i z i n g twD or three investigators to obtain data over a twenty-four hour period for the entire postoperative stay in the open-heart intensive care unit. 2. A study might be done to further analyze the environ-mental stimuli in .the postcardiotomy intensive care unit. 3. An experimental study u t i l i z i n g a different approach to organizing nursing care to allow the patient a maximum amount of uninterrupted time for rest and sleep. BIBLIOGRAPHY A. Books Colquhoun, LI. P. ed. 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Physiological Revieus 46 (January 1966): 129. Nahum, L. H. "Madness in the Recovery Room From Open-Heart Surgery or They Kept Waking Me Up." Connecticut Medicine 29 (November 1965) : 771-72. Pitorak, Elizabeth. "Alleviating Cardiac Patients' Fear Important Part of Nurse's Role." Hospital Topics 44 (May 1966): 126-27. Pitorak, Elizabeth F. "Open-Ended Care for the Open-Heart Patient." American Journal of Nursing 67 (July 1967): 1452-57. Rae, Nancy Mara. "Caring for Patients Follouing Open-Heart Surgery." American Journal of Nursing 63 (November 1963): 77-82. Sassin, J.F. "Neurological Findings Follouing Short Term Sleep Depriv-ation." Archives of Neurology 22 (January 1970): 54-56. Walker, Betty. "The Postsurgery Heart Patient: Amount of Uninterrupted Time for Sleep and Rest During the First, Second, and Third Post-Operative Days in a Teaching Hospital." Nursing Research 21 (March-April 1972): 164-69. Webb, Welse B., and Agneu, Harmon W. Jr. "Variables Associated uith Split Period Regimes." Aerospace Medicine 42 (August 1971): 847-50. Weitzman, E l l i o t D.; Kripke, Daniel F.; Goldmacher, Donald; McGregor, Peter; and Nogeire, Chris. "Acute Reversal of the Sleep-Waking Cycle in Man." Archives of Neurology 22 (June 1970): 483-89. Williams, R.L.; Agneu, Harman, W. Jr.; and Webb, Wilse B. "Sleep Patterns in the Young Adult Female; an EEG Study." Electroencepholography and Cli n i c a l Neurophysiology 20 (March 1966) : 264-66. Intensive Care Gives Patients L i t t l e Rest.(Neus) Journal American  Medical Association 210 (December 1969): 1682. 51 C. Government Publications U. S. Department of Health, Education and Welfare. Current Research  on Sleep and Dreams. Public Health Service Publication Mo. 1389, 1965. D. Unpublished Material Eluell, E. L. "Types of Interruptions and Amount of Sleep and Rest Obtained by Six Selected Past-Cardiotomy Patients on the First Three Postoperative Night." Unpublished Master's thesis, The University of Washington, Seattle, 1969. Garner, Susanna L. "Study of Sleep Deprivation and Nursing Activities Which Affect Sleep in Post-Cardiotomy Patients. Unpublished Master's thesis, University of Washington, Seattle, 1969. McFadden, E. H. "A Study of Sleep Deprivation in Patients Having Open-Heart Surgery." Unpublished Master's thesis, University of Washington, Seattle, 1968. APPENDIX A CHECKLIST OF INTERRUPTING ACTIVITIES 53 Date: Postoperative Day: 1 2 3 k 5 6 7 a 9 10 11 12 13 lk 15 Medication Bed Bath Oral Hygiene Dressing Linen Change Restraints Other Chest Auscult. Vital Signs Blood Pressure Temperature I.V. Monitor Lead C.V.P. Hypother.Blanket Turn-Postion Pass. Exercise Ambulation Strip Chest Tube Postural Drainage Cough-Deep Breathe I.P.P.B. IM.T. Tube Care Bag & Suction 02 Therapy Measure Urine Foley Catheter Bedpan-Urinal Fluids Offered Oral Feeding Weight Nurse Comm. c Pt. Pt. Initiated Act. Visitors Doctor Housekeeping Laboratory X-Ray Physio. Therapy Environment: Noise Lights Telephone Talking Monitor Alarm i APPENDIX B CATEGORIES DF TYPES DF ACTIVITIES 55 Categories of Types of Activities 1 . IMursing Activities a) Comfort d) medication bed bath oral hygiene dressing linen change restraints other b) Monitoring e) chest auscultation v i t a l signs blood pressure temperature I.V. monitor lead C.V.P. d) Circulation f) . hypothermia blanket turn and position passive exercises ambulation 2. Patient Initiated Activities 3. Activities of Others personal visitors doctors housekeeping staff laboratory staff X-ray physiotherapist k. Environment noise lights telephone talking monitor alarm Respiration strip chest tube postural drainage cough and deep breathe I . P . P . B . IM.T. tube care bag and suction 0^ therapy Nutrition and Elimination measure urine foley catheter bedpan - urinal fluids offered oral feeding weight Nurse communicating with patient APPENDIX C RANDOM SAMPLE OF TIME FDR OBSERVATION PERIODS RANDOM SAMPLE OF TIME FOR OBSERVATION PERIODS Early Postoperative Period 2:00 P.M. - 6:00 A.M.) Mon. Tues. wed. Thur. F r i . Sat. Sun. 2 AM - 6 AM 2 PM - 6 PM 10 PM - 2 AM 2 AM - 6 AM 2 PM - 6 PM 6 PM - 10 PM 6 PM - 10 PM 10 PM - 2 AM 10 PM - 2 AM Mid Postoperative Period (6:00 A.M. - 2:00 A.M.) 6 PM - 10 PM 10 PM - 2 AM 6 AM - 10 AM 6 AM - 10 AM 6 PM - 10 PM 10 PM - 2 AM 10 AM - 2 PM 2 PM - 6 PM 10 AM - 2 PM Late Postoperative Period (2:00 A.M. - 10:00 P.M.) 6 PM - 10 PM 6 AM - 10 AM 6 PM - 10 PM 10 AM - 2 PM 2 PM - 6 PM 2 PM - 6 PM 6 PM - 10 PM 10 AM - 2 PM • 2 AM - 6 AM Total time blacks: 6:00 A.M. - 10:00 A.M. = 3 6:00 P.M. - 10:00 P.M. = 7 10:00 A.M. - 2:00 P.M. = 4 10:00 P.M. - 2:00 A.M. = 5 2:00 P.M. - 6:00 P.M. = 5 2:00 A.M. - 6:00 A.M. = 3 APPENDIX D TABLES RELATED TD UNINTERRUPTED TIME BLOCKS TABLE 10 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN THE EARLY POSTOPERATIVE PERIOD Number of Uninterrupted Time Blocks Four-Hour Blocks Duration 5 mins. or less 6-10 mins. 11-20 mins. 21-30 mins. 31-40 mins. 41-50 mins. over 50 mins. 2-6 P. M. 32 k 1 . 1 0 0 0 2-6 P.M. 18 5. 1 . 1 0 1 0 6-10 P.M. 31 k 2 0 0 0 0 6-10 P.M. 19 4 2 1 0 0 0 10-2 A.M. 27 k 1 1 0 0 0 10-2 A.M. 30 7 1 1 0 0 0 10-2 A.M. 16 .0 0 1 0 1 0 2-6 A.M. 11 2 3 1 1 0 0 2-6 A.M. 29 6 3 0 0 0 0 Total 213 36 lk 7 1 2 0 U l TABLE 11 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN THE MID,POSTOPERATIVE PERIOD Four-Hour Blocks Number of Uninterrupted Time Blocks Duration 5 mins. 6-10 11-20 21-30 31-it0 41-50 over or less mins. mins. mins. mins. mins. 50 mins. 6-10 A.M. . 21 3 0 0 0 0 0 6-10 A.M. 16 1 5 0 2 0 0 10-2 P.M. 20 7 if 0 0 0 0 10-2 P.M. 11 2 3 0 0 0 0 2-6 P.M. 29 3 0 0 0 0 0 6-10 P.M. 28 1 1 1 0 0 0 6-10P.M. 17 0 1 1 0 0 0 10-2 A.M. 2k k if 0 0 0 0 10-2 A.-M. 15 5 3 1 0 0 0 Total 181 26 21 3 2 0 0 cn o TABLE 12 NUMBER AND DURATION OF UNINTERRUPTED TIME BLOCKS IN EACH FOUR-HOUR BLOCK IN,THE LATE POSTOPERATIVE PERIOD Number of Uninterrupted Time Blacks Four-Hour Duration Blocks 5 mins. or less 6-10 mins. 11-20 mins. 21-30 mins. 31-40 mins. 41-50 mins. over 50 mins. 2-6 A.M. 1.5 5 2 2 0 0 0 6-10 A.M. 21 3 0 0 0 0 10-2 P.M. 16 2 1 0 0 0 0 10-2 P.M. 30 2 •1 0 0 0 0 2 -6 P.M. 25 2 0 0 0 0 0 2-6 P.M. 7 2 2 1 1 0 0 6-10 P.M. 11 4 3 0 0 0 0 6-10 P.M. 25 5 1 0 0 0 0 6-10 P.M. 35 2 0 0 0 0 0 Total 185 27 14 3 1 0 0 APPENDIX E TABLES RELATED TD TYPES OF INTERRUPTIONS 63 TABLE 13 NUMBER DF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE EARLY : POSTOPERATIVE PERIOD Types of Activity Medication Bed Bath Oral Hyg. Dressing Linen Other Chest Ausc, V.S. B. P. Temp. I.V. Monitor C. V.P. Hypo.Blank Turn-Pos. Pass.Ex. Chest Tube Cough D.B. N.T. Tube Bag & Suet. 02 Ther. Meas.Urine Foley Cath. Nur. comm. Pt.Int.Act. Visitors Doctor Lab. X-ray Physio. Environ: Noise Lights Tel. Talking Mon.Alarm Total Number of Interruptions Four-Hour Time Blacks 2-6 P.M 1 1 14 B 13 12 3 2 2 19 1 91 2-6 P.M 2 6 11 15 1 1 • • 5 17 4 1 124 6-10 P.M. 5 .15 3 • • 3 4 2 4 2 11 10 1 3 • • 1 21 6 3 4 2 4 8 11 • • 4 22 152 6-10 P.M. 2 11 2 • • 4 5 • • 4 7 4 • • 8 7 • • 5 1 6 2 10 21 1 1 3 9 1 5 1 0.27 10-2 A.M. 3 1 11 2 3 6 5 10 10 • • 8 6 8 1 2 7 8 22 2 4 10 3 42 10-2 A.M. 6 2 8 5 5 5 11 4 2 • • 4 7 26 3 1 21 120 10-2 A.M. 8 2 12 2 9 8 5 7 3 29 5 38 • • 1 42 • • 85 2-6 A.M. 4 6 3 4 2. 1 7 5 1 4 1 • • 2 41 8 98 2-6 A.M. 7 6 7 3 1 6 17 2 0 • • 11 5 1 1 • • 3 2 81 Total 33 32 6 3 13 52 19 53 36 35 42 8 33 • • 73 1 40 15 19 29 25 7 5 65 126 26 16 5 7 48 109 6 11 115 7 .120 TABLE 14 NUMBER OF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE MID POSTOPERATIVE PERIOD Types of Activity Number of Interruptions 6-10 A.M. Medication 4 Bed Bath 12 Oral Hyg. 2 Dressing Linen . 4 Other 1 Chest Ausc. 3 V.S. 3 B. P. 6 Temp. 4 I.V. 4 Monitor 1 C. V.P. 2 Turn.P-as. 11 Pass. Ex 1 Chest Tube Caugh-D.B. 02 Ther. Meas.urine Foley Cath. Fluids Oral feed Nurse comm. 3 Pt.Init.Act 18 Visitors 16 Doctor 4 Housekeep Lab. X-ray 8 Physio. 41 Environ: Noise 34 Lights 1 Tel. 2 Talking 38 Mon.Alarm 2 Total |228 Four-Hour Time Blocks 6-10 A.M. 1 2 1 1 2 3 16 a 1 6 4 • • 10 66 10-2 P.M. 1 4 4 1 2 • • 1 23 • • 1 2 • • 22 4 5 1 74 10-2 P.M. 18 • • 4 5 2 4 • • 2 2 1 3 2 7 • o 4 20 4 70 11 21 1 187 P.Ml 3 6 1 15 3 2 • • 5 6 4 5 • • 13 6 4 5 6 7 18 34 16 26 1 191 6-10 P.M. 4 13 3 • • 9 19 6 6 • • 1 16 4 .5 4 17 7 11 23 • • 3 42 2 203 6-10 P.M. 1 14 • • 18 13 5 2 16 1 • • 12 5 t m 8 4 24 2 2 13 1 149 10-2 A.M. 8 3 4 4 4 7 2 4 2 2 1 18 23 10 1 • • 9 4 112 10-2| A.M. 1 2 1 3 2 8 1 2 1 34 18 20 1 3 8 110 65 TABLE 15 NUMBER OF INTERRUPTIONS IN THE TYPES OF ACTIVITY UITHIN THE FOUR-HOUR TIME BLOCKS IN THE LATE POSTOPERATIVE PERIOD Number of Interruptions Types of Activity Medication Bed Bath Oral Hyg. Dressing Linen Other Chest Ausc. V.S. B. P. Temp. I.V. Monitor C. V.P. Turn.Pas. Ambulation Chest Tube Caugh-D.B. 02 Ther. Meas.Urine Bed Pan Fluids Oral Feed Nur.camm. Pt.Int.Act. Visitors Doctor Housekeep' Lab. X-ray Physio. Environ: Noise Lights Tel. Talking Man.Alarm Four-Hour Time Blocks 2-6 A.M. 3 6 5 2 6 > • 3 2 49 7 1 1 1 97 6-10 A.M. 3 2 6 2 4 7 7 2 8 2 •3 1 1 20 a 5 27 15 1 3 7 3 141 10-2 P.M. 12 3 2 3 3 a 4 35 7 24 2 10 • • 23 11 • • 1 21 • • i a i 10-2 P.M. la l 6 • • 3 7 7 4 1 6 4 13 1 4 • • 1 11 a 37 • • 2 1 15 • • 22 16 • • 1 19 1 211 2-6 P.M. 5 9 2 • • 4 10 a 5 9 5 20 6 1 23 12 1 21 9 156 2-6 P.M. 2 2 6 40 • • 6 7 7 a 5 3 1 11 13 46 10 43 4 229 6-10 P.M. 3 21 1 4 11 3 4 2 7 5 a • • 4 1 • • 7 22 23 14 • • 1 26 • • 174 6-10 P.M. 3 25 10 a • • 5 8 a 14 • • 2 2 2 4 14 • • 1 2 • • 5 19 • • 3 25 2 165 6-10 P.M. 1 7 • • 1 13 11 • • 4 2 3 12 • • 1 7 30 17 1 13 14 4 21 2 179 Total 22 64 5 37 51 91 12 42 48 44 53 1 16 59 17 4 7 39 6 13 6 80 52 233 41 4 4 38 5 177 109 2 14 129 8 1533 APPENDIX F NUMBER OF PATIENTS OBSERVED BY SEX ACCORDING TO THE TYPE OF SURGERY 67 TABLE 16 NUMBER DF MALE AND FEMALE PATIENTS •BSERUED ACCORDING TO THE TYPE OF SURGERY Types of Surgery Number of Patients Male Female Aortic l/alv/e Replacement 1 • • Atrial Myoxma 1 • • Atrial Septal Defect • • 3 Mitral Valve Replacement 3 2 Open Mitral Commissurotomy • • 2 Single Bypass Graft k if Double Bypass Graft 5 • • Triple Bypass Graft 1 1 Total 15 12 APPENDIX G TABLES RELATED TO INTERRUPTED AND UNINTERRUPTED TIME 69 TABLE 17 NUMBER OF MINUTES OF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FOUR-HOUR BLOCK IN THE EARLY POSTOPERATIVE PERIOD Four-Hour Blocks Number of Minutes Interrupted Time Uninterrupted Time 2-6 P.M. 103 137 2-6 P.M. 78 162 6-10 P.M. 131 109 6-10 P.M. 108 132 10-2 A.M. 110 130 10-2 A.M. 93 147 10-2 A.M. 142 98 2-6 A.M. 63 177 2-6 A.M. 87 153 T o t a l 1,120 1,040 70 TABLE 18 NUMBER DF MINUTES DF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FOUR-HOUR BLOCK IN THE MID POSTOPERATIVE PERIOD Number of Minutes Four-Hour Blocks Interrupted Time Uninterrupted Time 6-10 A.M. 193 47 6-10 A.M. 54 186 10-2 P.M. 67 173 10-2 P.M. 153 87 2-6 P.M. 163 77 6-10 P.M. 128 112 6-10 P.M. 172 68 10-2 A.M. 94 146 10-2 A.M. 87 153 Tota l 1,320 840 71 TABLE 19 NUMBER OF MINUTES DF INTERRUPTED AND UNINTERRUPTED TIME IN EACH FDUR-BLDCK IN THE LATE POSTOPERATIVE PERIOD Number of Minutes Four-Hour Blacks Interrupted Time Uninterrupted Time 2-6 A.M. 72 168 6-10 A.M. 119 121 10-2 P.M. 176 64 10-2 P.M. 158 82 2-6 P.M. 183 57 2-6 P.M. 120 12D 6-10 P.M. 145 95 6-1-0 P.M. 141 99 6-10 P.M. 153 87 Total 1,533 627 

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